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Administrative (Non-Clinical) Policy
This administrative policy applies to the operations and staff of the University of Wisconsin Hospitals and
Clinics Authority (UWHCA) as integrated effective July 1, 2015, including the legacy operations and
staff of University of Wisconsin Hospital and Clinics (UWHC) and University of Wisconsin Medical
Policy Title: Inspection of Radiation Protection Items
Policy Number: 12.13
Effective Date: August 23, 2017
Chapter: Safety/Emergency Management
To establish guidelines for new personal radiation protection items (RPIs) and their continuing use.
II. POLICY ELEMENTS
A. RPIs for employees include, but are not limited to, aprons, gloves, vests, skirts, and thyroid
B. Acceptance testing of new radiation protection items shall be processed through the Clinical
Engineering Imaging Equipment Coordinator or designee.
C. An ongoing visual inspection of personal and patient radiation protection items is the
responsibility of each individual utilizing those items.
D. Fluoroscopic or radiographic inspection of radiation protection items will be conducted every two
E. Employee RPIs are required to be 0.5 mm lead equivalent or greater on the portion of the RPI
covering the front of the person. The portion of the RPI covering the back and sides of the person
(e.g., back and sides of skirts, vests, and wrap around aprons) shall have a lead equivalent
thickness of 0.25 mm or greater. All new RPIs are tested upon receipt to verify these
requirements prior to use.
F. Each section/department shall assign an individual(s) to be responsible as a RPI tester, to conduct
the biennial radiographic/fluoroscopic inspection of radiation protection items.
G. Cleaning Radiation Protection Items is the responsibility of the individual utilizing those items.
H. If personally acquired lead garments are brought into any department, they will be treated as new
and acceptance testing will need to be performed. Contact the Imaging Equipment Coordinator by
emailing: firstname.lastname@example.org to schedule the acceptance testing prior to use.
New Radiation Protection Items (RPIs)
A. The Imaging Equipment Coordinator or designee shall be notified by the section/department
when it acquires new personal radiation protection items. The Imaging Equipment Coordinator
can be reached by emailing email@example.com.
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B. The Imaging Equipment Coordinator or designee, upon receipt of new RPI, will:
1. Check the manufacturer’s label to verify that it is 0.5 mm lead equivalent or greater in
front and 0.25 mm or greater in back and sides. Each panel should be labeled with a
nominal lead equivalent thickness.
2. Measure the x-ray transmission through each panel of the RPI to ensure that it attenuates
x-rays at a level consistent with its nominal lead equivalent thickness.
3. Using a general purpose x-ray unit, set the table top to x-ray source distance to
approximately 75 cm, if possible. Put a dosimeter on the table top and collimate the x-
ray field to extend beyond the dosimeter by about 2 cm on each side. Put foam blocks or
something similar on both sides of the dosimeter to support the RPI panel approximately
2 cm above the dosimeter.
4. Set the x-ray techniques to 80 kV at 20 mAs and take an exposure with only the
dosimeter and foam blocks in the beam and record the dose. This is the unattenuated
5. Place the RPI panel on top of the foam blocks and dosimeter and take another exposure.
The panel should completely cover the collimated x-ray field. (Some panels attenuate x-
rays more in one direction than the other. The inside of the panel should be facing the
dosimeter in this case.) Record the attenuated dose. The attenuated dose should be no
greater than 2.5% of the an attenuated dose for a 0.5 mm lead equivalent panel, 5.5% for
a 0.35 mm panel, and 9% for a 0.25 mm panel
6. Repeat this procedure for each panel of the RPI.
7. If the attenuated dose is greater than the appropriate value, the panel fails the
transmission test and the item should be given to Medical Physics for further testing.
8. RPIs that fail transmission testing will be given back to the ordering department to be
returned to the manufacturer.
9. Record appropriate information into the inventory spreadsheet; each item will be marked
with a unique identification code and test date. Enter a service request on U-Connect for
Clinical Engineering (CE) to enter appropriate information into the CE equipment
tracking software and for CE to mark each item with a unique identification code with
10. If personally acquired lead garments are brought into any department they will be treated
as new and acceptance testing will need to be performed.
Current / In-Use Radiation Protection Items (RPIs)
A. On a daily basis and prior to use, employees utilizing RPIs shall visually inspect the item for
damage, unusual wear, and that the item has been radiographically/fluoroscopically checked
within the past two-years; if item does not pass visual or date inspection, do NOT use item, and
contact your section/department’s RPI tester(s) to conduct a radiographic/fluoroscopic test to
verify that the protection integrity is acceptable. Passing RPIs will have new dates; failing RPIs
shall be removed from use and sent to the Imaging Equipment Coordinator to be removed from
the CE software system and properly disposed.
B. If the RPI is visibly soiled, wipe down with the manufacturer’s recommended product.
1. If soiling with blood or body fluids has occurred, decontaminate the surface using a
UWH-approved disinfecting detergent as described in policy 4.1.4, Cleaning of Blood
and Body Fluid Spills.
C. When an invasive procedure requires isolation protection, the gown shall be worn over the RPI.
D. Every two years, a thorough cleaning of the RPI according to manufacturer’s directions using the
manufacturer’s recommended cleaning products will be done.
E. Every two years, RPI tester(s) shall radiograph/fluoro radiation protection items to verify that
protection integrity is acceptable. Passing RPIs will have new dates; failing RPIs shall be
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removed from use and sent to the Imaging Equipment Coordinator to be removed from the
inventory system and properly disposed.
Sr. Management Sponsor: VP, Facilities and Support Services
Author: Director, Life Safety
Reviewers: X-Ray Safety Committee; Environment of Care Safety Committee
Approval Committee: UW Health Administrative Policy & Procedure Committee
UW Health Chief Administrative Officer